journal of dentistry 39 (2011) 208–211

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Zirconia ceramic inlay-retained fixed dental prostheses – first

clinical results with a new design

Milia Abou Tara a,*, Stephanie Eschbach a,1, Stefan Wolfart b, Matthias Kern a
a
Department of Prosthodontics, Propaedeutics and Dental Materials, School of Dentistry, Christian-Albrechts-University at Kiel,
Arnold-Heller-Str. 16, 24105 Kiel, Germany
b
Department of Prosthodontics and Dental Materials, RWTH Aachen University, Aachen, Germany

article info abstract

Article history: Objectives: The purpose of this prospective study was to evaluate the clinical outcome of
Received 9 August 2010 inlay-retained fixed dental prostheses (IRFDPs) with a new design made from a zirconia
Received in revised form ceramic.
14 December 2010 Methods: Twenty-three 3-unit IRFDPs were placed in 23 patients, restoring five second
Accepted 18 December 2010 premolars and 18 first molars. Preparations were performed in accordance with general
principles for ceramic inlay restorations and modified with a retainer-wing bevel prepara-
tion in the enamel at the buccal and oral sides. The frameworks were scanned and milled
Keywords: out of zirconia ceramic, using the InLab CAD/CAM-system and the pontics were veneered
All-ceramic restorations with feldspathic ceramic. All IRFDPs were luted adhesively with composite resin. Clinical
Fixed dental prostheses follow-up examinations were performed annually. Statistical analysis was performed using
Inlay-retained descriptive statistics and Kaplan–Meier survival analysis.
Zirconia ceramic Results: All patients with their 23 IRFDPs could be examined clinically after a mean obser-
Clinical trial vation time of 20 months. None of the IRFDPs failed. Two ceramic veneers fractured, both of
them needed repair. One restoration debonded, but was recemented immediately. However,
these technical complications did not affect the clinical function of the IRFDPs involved.
Conclusions: The clinical outcome of zirconia ceramic IRFDPs with the modified design
seems promising.
# 2010 Elsevier Ltd. All rights reserved.

strength so far is achieved using zirconia ceramic as core

1. Introduction
The use of all-ceramic materials for fixed restorations in
dentistry has become more and more important for patients
and clinicians in recent decades. The growing interest in
biocompatible and aesthetically attractive restorations has
stimulated further development in this field. To increase the
mechanical strength of all-ceramic restorations, different
core materials were used, like lithium-disilicate based
glass-ceramic, glass-infiltrated alumina ceramic or pure
alumina ceramic. However, the highest fatigue fracture
material.1
Regardless the type of ceramic used, crown preparation
is always a risk to pulp vitality and may lead to pulpal
reactions in the long term.2 Approximately 63–73% of the
coronal tooth structure is removed when teeth are prepared
for all-ceramic crowns.3 Therefore the desire for inlay-
retained fixed dental protheses (IRFDPs), to adapt the type of
abutment preparation to the extent of sound tooth struc-
ture, has increased. Previous studies using lithium-disilicate
based glass-ceramic IRFDPs often failed to withstand
posterior masticatory forces.4–6

* Corresponding author at: Tel.: +49 431 597 2873; fax: +49 431 597 2860.
E-mail address: maboutara@proth.uni-kiel.de (M. Abou Tara).
1
Now at Private Dental Office, Freiburg, Germany.
0300-5712/$ – see front matter # 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jdent.2010.12.005
 journal of dentistry 39 (2011) 208–211
[()TD$FIG]
Fig. 1 – (A)–(C): Preparation design (A) and IRFDP in situ dated at baseline (B) and after 28 months of clinical function (C).
Laboratory studies showed higher load-bearing capacities
of IRFDPs made from zirconia ceramic than made from
lithium-disilicate ceramic.7–8 However, in a recently published
clinical study with zirconia ceramic IRFDPs,9 failures like
debondings and partially even framework fractures occurred
in 20% of the restorations during an observation period of only
12 months.
To improve the outcome of all-ceramic IRFDPs, not only the
core material has to demonstrate a high fracture resistance
but the design of the IRFDPs has to be reconsidered to
minimize the risk of debonding. Therefore Wolfart and Kern10
introduced in 2006 a new design of zirconia ceramic IRFDPs
using additional short retainer-wings at the buccal and oral
sides, to improve stress distribution and to increase the
adhesive bonding area. The purpose of this prospective study
was to evaluate the clinical outcome of zirconia-based all-
ceramic IRFDPs in the posterior region with this new design.
2. Materials and methods
Twenty-three 3-unit IRFDPs were placed in 23 patients (13
females, 10 males, mean age 43.7 years). IRFDPs replaced 5
second premolars (3 in the maxilla, 2 in the mandible) and 18
first molars (12 in the maxilla, 6 in the mandible). Tooth-
preparations were performed in accordance with general
principles for ceramic inlay restorations and in accordance to
the individual abutment tooth defect. Box-shaped inlay
cavities were prepared. Preparations were modified with a
retainer-wing bevel preparation in the enamel at the buccal
and oral side. The enamel was reduced about 0.2–0.5 mm
209
parallel to the insertion direction of the boxes, to achieve a
plain enamel area about 3 mm in height and at least 3 mm in
length (Fig. 1A).
All abutment teeth were vital and had no periodontal
diseases. After tooth preparation, impressions were made
using simultaneous dual-mix technique with polyether
material (Permadyne, 3 M ESPE, Seefeld, Germany). In the
laboratory, the impressions were cast with die stone type 4
(Fujirock, GC Europe, Leuven, Belgium). The framework was
modelled in resin (Pattern Resin, GC Europe) and then scanned
and milled out of zirconia ceramic (Vita In-Ceram YZ, Vita
Zahnfabrik, Bad Säckingen, Germany) using the InLab com-
puter-aided-design/computer-aided-manufacturing-(CAD/
CAM-)system (Sirona, Bensheim, Germany). The enlarged
green-state framework was then sintered at 1530 8C using a
special furnace (VITA ZYrcomat, Vita Zahnfabrik). The
minimum extension for the proximal connector was 3 mm
in height and 3 mm in width. The minimum occlusal ceramic
thickness was 1.2 mm. The proximal wing-extension was
minimum 3 mm in length and at least 0.6 mm thick. The
pontics were veneered with feldspathic ceramic (VITA VM 9,
Vita Zahnfabrik).
Standard adhesive luting techniques were performed using
the total-etch technique with 37% phosphoric acid (Total Etch,
Ivoclar-Vivadent, Schaan, Lichtenstein) and a dentine adhe-
sive (Clearfil New Bond, Kuraray, Japan). IRFDPs were
airborne-particle abraded (50 mm, Al2O3) with 2.5 bar pressure
and luted with a composite resin (Panavia 21 TC, Kuraray)
(Fig. 1B). Rubber dam was used during adhesive cementation.
Clinical follow-up examinations were performed after 6–12
months, then annually (Fig. 1C). Statistical analysis was
210 journal of dentistry 39 (2011) 208–211
[()TD$FIG]
Fig. 2 – (A) and (B) Ceramic veneering fracture at the pontic
with exposure of the core after 7 months (A) and the
intraoral repair with an occlusal ceramic table top
(lithium-disilicate glass-ceramic) in the follow-up after 37
months of clinical function (B).
performed using descriptive statistics and the survival rate
according to Kaplan–Meier survival analysis.
3. Results
Twenty-three patients with 23 IRFDPs were examined after a
mean observation time of 20 months (minimum 12, maximum
37). No biological complications such like caries or loss of
vitality were recorded. Technical complications consisted of
two veneering ceramic chippings (8.7%); both of them needed
repair, in one case the core material of the pontic was exposed
(Fig. 2A–B, Table 1). One IRFDP debonded after 24 months, but
could be recemented immediately. Visual examination
showed a mixed failure, i.e. resin cement remained partially
on the bonding surface of the restoration and partially on the
abutment teeth. Nevertheless, these technical complications
did not affect the clinical function of the IRFDPs involved.
Table 1 – Clinically relevant complications.
Restoration no and category Replaced tooth*
1-partial success 26
17-partial success 26
17-partial success 26
*
FDI tooth-numbering system.
[()TD$FIG]
Fig. 3 – Cumulative survival rate according to Kaplan–Meier
analysis regarding the criterion veneering ceramic fracture
as total loss.
However, no fractures of the frameworks occurred during
the observation period. The cumulative survival rate accord-
ing to Kaplan–Meier analysis was 100% after 20 months,
regarding the restoration being still in clinical function.
Regarding the veneering ceramic chipping as total failure,
the cumulative survival rate is shown in Fig. 3.
4. Discussion
In previous studies with all-ceramic IRFDPs made from a
lithium-disilicate glass-ceramic, failures were evoked by
debonding or a combination of debonding and fracture at
the isthmus of one abutment. Failure rates of these lithium-
disilicate ceramic based IRFDPs reached 13% after a mean
observation time of 37 months5 and even increased to 43%
after 5 years and 62% after 8 years in the follow-up of the same
study.6
However, even when the high-strength core material
zirconia ceramic was used for IRFDPs, but without the
modification of additional retainer-wings,9 more than 20%
failures like debondings and framework fractures occurred
during an observation time of only 12 months.
Different factors may be responsible for the reported
failures of IRFDPs in the above studies. High stress on the
luting cement because of different kinds of torsion forces on
the inlay retainers and a high percentage of dentine instead of
enamel at the interface between tooth and luting cement have
been suggested as causes for debonding.5 In a recent meta-
analysis of Pjetursson et al.11 about various resin-bonded fixed
dental prostheses (RBFDPs) approximately 23% debondings
after 5 years were reported for posterior RBFDPs.
Failure mode Failure region* Consequence of failure
Chipping 26 Palatinal cusps Intraoral repair
Chipping 26 Buccal cusps Repair
Debonding 25–27 Recementation
 journal of dentistry 39 (2011) 208–211
The modified design of IRFDPs seems to address these main
weak points: the CAD/CAM-manufactured zirconia ceramic
framework was used because of the significantly higher static
and fatigue fracture strength as compared to other ceramic
materials.7,12–13 With the preparation of the two accessory
retainer-wings not only the bonding surface area in the
enamel was increased but also the stress distribution of
functional loads was improved.14 Most of the preparation was
located in the enamel and only the shallow inlay preparation
was located superficial in dentine.
In addition, the surface conditioning method of the zirconia
ceramic will influence bonding to zirconia ceramic framework.
The combination of airborne-particle abrasion and phosphate
ester monomer (10-methacryloyloxydecyl dihydrogen phos-
phate [MDP] containing composite resin showed high and
durable bond strengths15–18 which seems to be clinically
sufficient as only one debonding occurred in the current study.
The failure mode of the debonded restoration was mixed, i.e.
resin cement remained partially on the restoration and partially
on the abutment teeth. Therefore, it can be assumed that not
the conditioned bonding surfaces of the restoration or the teeth
were the weakest link in the failed restoration but the cohesive
strength of the luting resin itself. In contrast, when using
tribochemical silica coating and silanating of zirconia ceramic
IRFDPs, debonding of the inlays with adhesive failure between
the zirconia ceramic and the luting resin was the most frequent
cause of failures within the first 12 months.9
The rate of further technical complications like the
veneering ceramic chipping was 8.7% after 20 months in this
study. This was in the range of various all-ceramic FDPs as
reported in a meta-analysis from Sailer et al.,19 ceramic
chipping ranged from 6.6% to 26% after 5 years. Especially with
zirconia-based ceramic restorations, the most frequent
technical problems were minor chipping or extended fracture
of the veneering ceramic.
5. Conclusions
These preliminary clinical results with zirconia ceramic
IRFDPs constructed in the modified design are promising.
However, long-term results are needed before these restora-
tions can be recommended for general clinical use.
Acknowledgements
This study is supported by Vita Zahnfabrik, Bad Säckingen,
Germany. The authors are grateful to the patients for their kind
cooperation and want to thank the dental technicians B.
Schlueter and R. Gerhardt for their work (Department of
Prosthodontics, Propaedeutics and Dental Materials, School of
Dentistry, Christian-Albrechts University at Kiel).
references
1. Koutayas SO, Vagkopoulou T, Pelekanos S, Koidis P, Strub JR.
Zirconia in dentistry. Part 2. Evidence-based clinical
211
breakthrough. The European Journal of Esthetic Dentistry
2009;4:348–80.
2. Bergenholtz G, Nyman S. Endodontic complications
following periodontal and prosthetic treatment of patients
with advanced periodontal disease. Journal of Periodontology
1984;55:64–8.
3. Edelhoff D, Sorensen JA. Tooth structure removal associated
with various preparation designs for anterior teeth. The
Journal of Prosthetic Dentistry 2002;87:503–9.
4. Edelhoff D, Spiekermann H, Yildirim M. Metal-free inlay-
retained fixed partial dentures. Quintessence International
2001;32:269–81.
5. Wolfart S, Bohlsen F, Wegner SM, Kern M. A preliminary
prospective evaluation of all-ceramic crown-retained and
inlay-retained fixed partial dentures. The International Journal
of Prosthodontics 2005;18:497–505.
6. Harder S, Wolfart S, Eschbach S, Kern M. Eight-year outcome
of posterior inlay-retained all-ceramic fixed dental
prostheses. Journal of Dentistry 2010;38:875–81.
7. Wolfart S, Ludwig K, Uphaus A, Kern M. Fracture strength of
all-ceramic posterior inlay-retained fixed partial dentures.
Dental Materials 2007;23:1513–20.
8. Puschmann D, Wolfart S, Ludwig K, Kern M. Load-bearing
capacity of all-ceramic posterior inlay-retained fixed
dental prostheses. European Journal of Oral Sciences
2009;117:312–8.
9. Ohlmann B, Rammelsberg P, Schmitter M, Schwarz S,
Gabbert O. All-ceramic inlay-retained fixed partial dentures:
preliminary results from a clinical study. Journal of Dentistry
2008;36:692–6.
10. Wolfart S, Kern M. A new design for all-ceramic inlay-
retained FPDs. A report of two cases. Quintessence
International 2006;37:27–33.
11. Pjetursson BE, Tan WC, Tan K, Brägger U, Zwahlen M, Lang
NP. A systematic review of the survival and complication
rates of resin-bonded bridges after an observation period
of at least 5 years. Clinical Oral Implants Research
2008;19:131–41.
12. Koutayas SO, Kern M, Ferraresso F, Strub JR. Influence of
design and mode of loading on the fracture strength of all-
ceramic resin-bonded fixed partial dentures. An in-vitro
study in a dual-axis chewing simulator. The Journal of
Prosthetic Dentistry 2000;83:540–7.
13. Mehl C, Ludwig K, Steiner M, Kern M. Fracture strength of
prefabricated all-ceramic posterior inlay-retained fixed
dental prostheses. Dental Materials 2010;26:67–75.
14. Aboushelib MN, Feilzer AJ, Kleverlaan CJ, Salameh Z. Partial-
retainer design considerations for zirconia restorations.
Quintessence International 2010;41:41–8.
15. Kern M, Wegner SM. Bonding to zirconia ceramic:
adhesion methods and their durability. Dental Materials
1998;14:64–71.
16. Wegner S, Kern M. Long-term resin bond strength to
zirconia ceramic. Journal of Adhesive Dentistry 2000;2:
139–45.
17. Yang B, Scharnberg M, Wolfart S, Quaas AC, Ludwig K,
Adelung R, et al. Influence of contamination on bonding to
zirconia ceramic. Journal of Biomedical Materials Research Part
B Applied Biomaterials 2007;81:283–90.
18. Kern M. Resin bonding to oxide ceramics for dental
restorations. Journal of Adhesion Science and Technology
2009;23:1097–111.
19. Sailer I, Pjetursson BE, Zwahlen M, Hämmerle CHF. A
systematic review of the survival and complication rates
of all-ceramic and metal-ceramic reconstructions after an
observation period of at least 3 years. Part II: fixed
dental prostheses. Clinical Oral Implants Research
2007;18:86–96.